National Public Health Performance Standards Program Orientation to the Essential Public Health Services

A little history… Three core functions (1988 IOM Report) Assessment Policy Development Assurance Core Functions Steering Committee (1994) Public Health in America statement First, a little history. Many of you may be familiar with the core functions, which were outlined in the 1988 Institute of Medicine report - The Future of Public Health. As stated in the IOM report, the three core functions of public health are assessment, policy development and assurance. This is a good start to describing public health, but 1994, when the country was exploring issues related to health care reform, the public health sector felt that a better definition and description of public health was needed. A “Core Functions of Public Health Steering Committee” was convened to address this need. This Steering Committee involved representatives from Public Health Service Agencies (CDC, HRSA, Office of Disease Prevention and Health Promotion, etc.) and key National Public Health Organizations. The committee produced a statement called “Public Health in America.”

Essential Public Health Services Developed by the Core Public Health Functions Steering Committee (1994) Included reps from national organizations and federal agencies Charge: To provide a description and definition of public health Developed the “Public Health in America” statement

Healthy People in Healthy Communities Vision: Healthy People in Healthy Communities Mission: Promote Physical and Mental Health and Prevent Disease, Injury, and Disability Public Health in America – Vision and Mission The Public Health In America statement provides a vision and mission for public health as well as the context of what public health should be prepared to do and how public health service is delivered. The vision for public health is broad, “Healthy People in Healthy Communities.” The mission identified is to “Promote Physical and Mental Health and Prevent Disease, Injury, and Disability”.

Public Health Prevents epidemics and the spread of disease Protects against environmental hazards Prevents injuries Promotes and encourages healthy behaviors Responds to disasters and assists communities in recovery Assures the quality and accessibility of health services The Public Health in America statement also includes a section that defines the “purpose” of public health. These include: Preventing epidemics and the spread of disease Protecting against environmental hazards Preventing injuries Promoting and encouraging healthy behaviors Responding to disasters and assists communities in recovery Assuring the quality and accessibility of health services

Essential Services of Public Health Monitor health status Diagnose and investigate Inform, educate, and empower Mobilize community partnerships Develop policies and plans Enforce laws and regulations Link people to needed services / assure care Assure a competent workforce Evaluate health services Research The last part of the Public Health in America statement defines the “Essential Services of Public Health”. The ten essential services are shown up here on the screen and include: Monitor health status to identify and solve community health problems Diagnose and investigate health problems and health hazards in the community Inform, educate, and empower people about health issues Mobilize community partnerships to identify and solve health problems Develop policies and plans that support individual and community health efforts Enforce laws and regulations that protect health and ensure safety Link people to needed personal health services and assure the provision of health care when otherwise unavailable Assure a competent public and personal health care workforce Evaluate effectiveness, accessibility, and quality of personal and population-based health services Research for new insights and innovative solutions to health problems Basically, any public health activity can fit into one of these ten categories. So for example, Essential Service #1 includes activities such as data collection, community health assessments and the maintenance of population health registries. As another example, Essential Service #7 includes personal health care services as well as transportation and other enabling services and assuring the availability of culturally appropriate personnel and materials. Since the release of the ten Essential Services, numerous initiatives have explored the utility and feasibility of these services and have found them to be a good descriptor of public health.

The Essential Services as a Framework Used as a foundation for the National Public Health Performance Standards Program (NPHPSP) instruments Provides a foundation for any public health activity Describes public health at both the state and local levels NPHPSP Instruments include sections addressing each ES The Essential Public Health Services provide the fundamental framework for the NPHPS instruments. By describing the public health activities that should be undertaken in all communities, these activities describe the full range of public health responsibilities. In 1994, the Core Public Health Functions Steering Committee (convened by DHHS) developed this list of responsibilities. Using the Essential Services assures that the standards fully cover the gamut of public health activities needed at state and community levels. When you look at the 3 different NPHPSP instruments, you will see that each includes a chapter or section devoted to each Essential Service.

NPHPSP Assessment Instruments Partners State public health system Local public health system Local governance Partners CDC APHA ASTHO NACCHO NALBOH NNPHI PHF

The EPHS “in English” Understand health issues at the state and community levels (Or “what’s going on in our state/community? Do we know how healthy we are?”) Identify and respond to health problems or threats (Or “Are we ready to respond to health problems or threats? How quickly do we find out about problems? How effective is our response?”) Keep people informed about health issues and healthy choices. (Or “How well do we keep all people and segments of our State informed about health issues?”) The ten essential services are shown here on the screen and include: Monitor health status to identify and solve community health problems. Diagnose and investigate health problems and health hazards in the community. Inform, educate, and empower people about health issues. Mobilize community partnerships to identify and solve health problems. Develop policies and plans that support individual and community health efforts. Enforce laws and regulations that protect health and ensure safety. Link people to needed personal health services and assure the provision of health care when otherwise unavailable. Assure a competent public and personal health care workforce. Evaluate effectiveness, accessibility, and quality of personal and population-based health services. Research for new insights and innovative solutions to health problems These are the foundation of any public health activity. For example, any public health program needs data to operate. Essential Service #1 includes activities such as data collection, community health assessments and the maintenance of population health registries. As another example, Essential Service #7 includes personal health care services, transportation and other enabling services such as assuring the availability of culturally appropriate personnel and materials. Since the Ten Essential Services were released, numerous initiatives have explored the utility and feasibility of these services and have found them to be a good descriptor of public health practice.

The EPHS “in English” 4. Engage people and organizations in health issues. (Or “How well do we really get people and organizations engaged in health issues?”) 5. Plan and implement sound health policies. (Or “What policies promote health in our State? How effective are we in planning and in setting health policies?”) Enforce public health laws and regulations. (Or “When we enforce health regulations are we up-to-date, technically competent, fair and effective?”) The ten essential services are shown here on the screen and include: Monitor health status to identify and solve community health problems. Diagnose and investigate health problems and health hazards in the community. Inform, educate, and empower people about health issues. Mobilize community partnerships to identify and solve health problems. Develop policies and plans that support individual and community health efforts. Enforce laws and regulations that protect health and ensure safety. Link people to needed personal health services and assure the provision of health care when otherwise unavailable. Assure a competent public and personal health care workforce. Evaluate effectiveness, accessibility, and quality of personal and population-based health services. Research for new insights and innovative solutions to health problems These are the foundation of any public health activity. For example, any public health program needs data to operate. Essential Service #1 includes activities such as data collection, community health assessments and the maintenance of population health registries. As another example, Essential Service #7 includes personal health care services, transportation and other enabling services such as assuring the availability of culturally appropriate personnel and materials. Since the Ten Essential Services were released, numerous initiatives have explored the utility and feasibility of these services and have found them to be a good descriptor of public health practice.

The EPHS “in English” Make sure people receive the medical care they need. (Or “Are people receiving the medical care they need?”) Maintain a competent public health and medical workforce. (Or “Do we have a competent public health staff? How can we be sure that our staff stays current?”) Evaluate and improve programs. (Or “Are we doing any good? Are we doing things right? Are we doing the right things?”) Support innovation and identify and use best practices. (Or “Are we discovering and using new ways to get the job done?”) The ten essential services are shown here on the screen and include: Monitor health status to identify and solve community health problems. Diagnose and investigate health problems and health hazards in the community. Inform, educate, and empower people about health issues. Mobilize community partnerships to identify and solve health problems. Develop policies and plans that support individual and community health efforts. Enforce laws and regulations that protect health and ensure safety. Link people to needed personal health services and assure the provision of health care when otherwise unavailable. Assure a competent public and personal health care workforce. Evaluate effectiveness, accessibility, and quality of personal and population-based health services. Research for new insights and innovative solutions to health problems These are the foundation of any public health activity. For example, any public health program needs data to operate. Essential Service #1 includes activities such as data collection, community health assessments and the maintenance of population health registries. As another example, Essential Service #7 includes personal health care services, transportation and other enabling services such as assuring the availability of culturally appropriate personnel and materials. Since the Ten Essential Services were released, numerous initiatives have explored the utility and feasibility of these services and have found them to be a good descriptor of public health practice.

Monitor Health to Identify and Solve Community Health Problems Accurate, periodic assessment of the community’s health status, including: Identification of health risks Attention to vital statistics and disparities Identifications of assets and resources Utilization of methods and technology (e.g., GIS) to interpret and communicate data Population health registries Monitor Health Status to Identify and Solve Community Health Problems Now let’s look at each of the services in more detail. This service includes accurate diagnosis of the community’s health status; identification of threats to health and assessment of health service needs; timely collection, analysis, and publication of information on healthcare access, utilization, costs, and outcomes of personal health services; and attention to the vital statistics. Motoring conditions that influence health are decentralized across the community. Data is maintained by police on crime, drug use, and traffic-related injuries. Fire departments collect information on smoke detectors, fire-related injuries, and location of toxic chemical in the community. Hospitals have discharge and emergency services data. Schools have attendance data, student immunizations data, and graduation rates. Many other system partners have important data as well. All of this data when brought together helps describe health in the community. This service informs decision-makers on health matters and supports selection of effective policy, plans and interventions to improve health. Efficient and effective use of computer and communication technology is needed to assure information is timely.

Diagnose and Investigate Health Problems and Hazards in the Community Timely identification and investigation of health threats Availability of diagnostic services, including laboratory capacity Response plans to address major health threats Diagnose and Investigate Community Health Problems and Hazards This service includes epidemiological identification of emerging health threats; public health laboratory capability using modern technology to conduct rapid screening and high volume testing; active infectious disease epidemiology programs; and technical capacity for epidemiological investigation of disease outbreaks and patterns of chronic disease and injury. This service draws heavily on epidemiology and laboratory diagnostic services. Within this service, public health and its system partners establish protocols for contact and source tracing as well as incident specific responses to address infectious disease and toxic agents found in the community. Risk assessment and hazard analysis, offered through this service, supports regulatory compliance programs and enforcement actions. Within these protocols are specific guidance on communicating information to appropriate system partners so they can take appropriate action on diagnosis and investigation findings. Communicating to the public is implemented through EPHS 4 – the inform and educate service but it is informed by protocol from this service.

Inform, Educate, and Empower People About Health Issues Initiatives using health education and communication sciences to: Build knowledge and shape attitudes Inform decision-making choice Develop skills and behaviors for healthy living Health education and health promotion partnerships within the community to support healthy living Media advocacy and social marketing Inform, Educate and Empower People About Health Issues This service involves: Making health information and educational resources accessible; Providing health information and education activities that shape attitudes and build knowledge necessary to reduce health risk and promote better health; Establishing health communication plans and activities that use media advocacy and social marketing approaches to shape attitudes and build knowledge; Enabling informed decision-making among individuals in making health choices and among leaders establishing health policies for the community. Maintaining health education and promotion program partnerships with schools, faith communities, work sites, personal care providers, and others to implement and reinforce health promotion programs that shape attitudes, knowledge, skills, and behaviors needed in a healthy community populations. These activities assist to empower people to make informed decisions regarding individual and community health matters.

Mobilize Community Partnerships to Identify and Solve Health Problems Constituency development and identification of system partners and stakeholders Coalition development Formal and informal partnerships to promote health improvement Mobilize Communities to Identify and Solve Community Health Problems Community health improvement is a collaborative effort requiring: Skilled conveners and organizers, Social responsiveness (above self-interest) from community members, and System structures that link community assets and the public’s will to act. One person or organization can start community change but neither can make change alone. It is critical for public health system leaders to effectively convene and organize for community actions that can improve health. Actions within the public health system that demonstrate this service are: Convening and facilitating multiple community groups to undertake health improvement work. Convener should seek to include those that are not typically considered to be involved in health-related matters. Mobilized groups can undertake defined preventive, screening, and rehabilitation initiatives, or support other programs activities that influence health. The building of coalition is one form or system to facilitate collaboration. Other forms exist. The key however is that structures must be maintained to support the mobilization of the community in order to draw upon the full range of community assets including people, organizations, and the physical environment that can support the improvement of health. Many broadly focused processes of community action exist across the U.S. under names like Healthy Communities, Livable Communities, and Loveable Communities. An even greater number of issue specific processes exist and are addressed under names such as Healthy Mothers and Babies, Mother’s Against Drunk Driving, and many, many other collaborative groups taking action to address environmental, economic, historical, and other efforts that can improve community health and quality of life.

Develop Policies and Plans That Support Community Health Efforts That Support Individual and Community Health Efforts Policy development to protect health and guide public health practice Community and state planning Alignment of resources to assure successful planning Develop Policies and Plans That Support Community Health Efforts Policies addressing specific health-related issues are public statements establishing directions individuals, organizations, or governments follow to protect and promote health. Policies are established by organizations and governments to identify consistent behaviors that are expected. Community and organization leaders have responsibility to articulate policies built on proven scientific finding and shaped by community values. Policies having negative or positive influences on health touch every aspect of community life. Safety standards that makers of automobiles and producers of electrical materials follow demonstrate policies that protect people from injury. Food handling guidelines protect people from illness. Other policy examples designed to encourage or support healthy behaviors can be identified in zoning rules. For example, zoning that requires sidewalks in new residential developments. This type of policy has influence on health by supporting the opportunity for physical activity as well as improving pedestrian safety. In addition, organizational leaders can influence health with policies that govern use of tobacco at company facilities, the availability of health insurance for employees, or facilities and time that allow for and promote physical activity. These are all examples of health-related policies that are important for community leaders to understand and apply. How well is health-related policy used to improve health in our community? Health plans provide strategic and operational guidance on how to improved health. Plans establish a set of objectives and related actions to make measurable health improve. Community health plans are more likely to be accepted and applied if the plans are made with the active participation of those the plans affect. Establishing a community health improvement plan builds on other essential services that result in development of good community health data, use of relevant public health science in decision-making, effective community education, establishment of supportive health-related policies, and mobilization efforts necessary to bring about health improvements. Community health improvement is not limited to issues classified within traditional public health or health services categories, but may include environmental, business, economic, housing, land use, and other community issues indirectly affecting the public’s health. This service represents decision-making and action to plan and measure general community health improvement. In addition, this essential service addresses more specific health plans like those that focus on preparation and response to disasters and all the human health and environmental implications resulting from disasters.

Enforce Laws and Regulations That Protect Health and Ensure Safety Review, evaluation, and revision of legal authority, laws, and regulations Education about laws and regulations Advocating of regulations needed to protect and promote health Support of compliance efforts and enforcement as needed Enforce Laws, Regulations, and Rules That Protect Health and Ensure Safety Governmental officials form public health and other regulatory officials have responsibility to assess legal authority and effectiveness of regulations. If regulations are not based on appropriate public health science and contemporary practice standards or if there are new regulations needed to properly protect health, public health leaders should advocate for needed regulator change. The primary purpose of health-related regulation is not punishment but compliance. Public health should employ the use of education and other methods to enable individuals and organizations to comply with health and safety regulations. If there is failure to comply, it is essential that public health use its enforcement authority to protect the public. Compliance and enforcement areas for public health include sanitary codes, especially in the food industry; protection of drinking water supplies; enforcement of clean air standards; protection from toxic and physical hazards in the environment; and monitoring the quality of medical services delivered through facilities such as laboratories, nursing homes, and home healthcare agencies.

Link People to Personal Health Services Link People to Needed Personal Health Services and Assure the Provision of Health Care when Otherwise Unavailable Identifying populations with barriers to care Effective entry into a coordinated system of clinical care Ongoing care management Culturally appropriate and targeted health information for at risk population groups Transportation and other enabling services Link People to Personal Health Services This service (often referred to as the "outreach" or "enabling" service) includes assuring effective entry of people into a coordinated system of clinical care, especially the socially disadvantaged. This may involve identifying and addressing potential barriers related to cultural, language of materials, or staff serving special population groups. It most certainly involves providing people access and linkage to a coordinated system of personal healthcare that provides ongoing "care management," transportation services, and targeted health information to high risk population groups. The system should also ensure delivery of effective health promotion and disease prevention services within the community as well as provision of technical assistance to community providers who wish to improve or offer health promotion services.

Assure a Competent Public and Personal Healthcare Workforce Assessment of the public health and personal health workforce Maintaining public health workforce standards Efficient processes for licensing / credentialing requirements Use of public health competencies Quality improvement and life-long learning Leadership development Cultural competence Assure a Competent Public and Personal Health Care Workforce This service includes: Education and training for personnel to meet the needs for public and personal health service; Efficient processes for licensure of professionals and certification of facilities with regular verification and inspection follow-up; Adoption of continuous quality improvement and life-long learning within all licensure and certification programs; Active partnerships with professional training programs to assure community-relevant learning experiences for all students; and Continuing education in management and leadership development programs for those charged with administrative or executive roles. Actions to achieve the intent of this service may include assessing the supply and competencies of those providing person healthcare and public health services. Assuring health workers are properly trained and recognized by licensure or other credentialing processes. Supporting access to a system for life-long learning to maintain and grow health worker competencies, including the provision of mentors who can cultivate leadership and cultural competencies within the workforce.

Evaluate Effectiveness, Accessibility, and Quality of Personal and Population-based Health Services Evaluation answers Are we doing things right? Are we doing the right things? Evaluation must be ongoing and should examine: Personal health services Population based services The public health system Evaluation should drive resource allocation and program improvement Evaluate Effectiveness, Accessibility, and Quality of Health Services This service calls for ongoing evaluation of health programs, based on analysis of health status and service utilization data, to assess program effectiveness and to provide information necessary for allocating resources and reshaping programs. Its through this service we should answer the questions Are we doing things right? and Are we doing the right things to effectively improve health? Evaluation must be seen as a consistent part of all public health work. Evaluation can be identified in many forms such as customer service feedback, quality improvement programs that examine the process of service delivery, or rigorous case control evaluation. All levels of evaluation are needed. Evaluation is needed for effective decision-making and resource allocation. It is through evaluation that we understand our improvements.

Research for New Insights and Innovative Solutions to Health Problems Identification and monitoring of innovative solutions and cutting-edge research to advance public health Linkages between public health practice and academic / research settings Epidemiological studies, health policy analyses and health systems research. Research for New Insights and Innovative Solutions to Health Problems This service includes continuous linkage with appropriate institutions of higher learning and research and an internal capacity to mount timely epidemiological and economic analyses and conduct needed health services research. Public health professionals have great opportunity to develop new information needed to better understand how community health can be improved. Necessity often requires innovative solutions to the health problems State and local public health professionals face. Most of our health service advances originated from the experience and insight of frontline public health workers and confirmed in collaboration study with health researchers. Public health at the State and local level must develop the capacity to participate in and guide health services research. Linkages must be established with research and academic centers in order to stimulate and capture new insights and innovations we need to public health problems. Such research must be fully participatory with those it studies and intend to affect.